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Children with DS, like all other children want to turn over, crawl, reach and explore the world around them and how to interact with it. In order to do this, they must develop gross motor skills (turning over, crawling). Because of some physical characteristics which include Hypotonia (low muscular tonus), soft ligaments( flexibility of bone joints) and lack of strength, kids with DS don't develop the same motor skills as kids with typical development.

The goal of physical therapy is not speeding the children's scale of development, like its often supposed, but rather ease normal development in moving. This means , that the child will be helped to develop a good stance, proper leg stretching, proper walking and a good physical base for training for the rest of their life.

What happens in a physical therapy session? First, we must observe what abilities the child already masters. Then we must determine what the child will learn next. It is very important to set realistic goals every month rather than learn things too advanced for him. Once we know which skills the child is able to master, the therapist creates his own way to teach him. Teaching strategies are based in the child's learning styles and the child's physique. One of the most important things a therapist must do is to also teach the parents how to practice the skills with their children. The parents can practice with their children once they feel strong and rested, so the abilities might be incorporated in the daily routine. Through practice and repetition the child will develop efficacy and strength which will lead him to mastering the skills.

What role does the child's temperament play in physical therapy? With temperament we understand a person's characteristic way of thinking, behaving and reacting. When children are taught a gross motor skill, we might observe models of thinking, behaving and reacting. Understanding a child's temperament and what motivates him will help us be efficient in teaching him gross motor skills. We must know beforehand which activities the child might like and which he will be more likely to resist. By knowing this, we might start with the activities the child likes and proceed with less likable activities once the child is in a good mood.

Some tips on what parents must know when they work with their children's motor skills. Mastering gross motor skills is the first step which parents and children with DS can face together. This is a good opportunity for the parents to start understanding how their children learn.

To determine what motivates your child. Your children is more likely to cooperate once he is motivated. Example: He might crawl to reach for a toy he likes. While you're practicing your child's motor skills, his success and pleasure will depend on the way you play the games with him.

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In language therapy there are programs about communication and spoken language. Communication consists in language ability, ability to be understood by others without having to speak, in becoming understandable and responding to surrounding environment . This program is divided in three parts which are:

• 1. base audio reaction = responding to sound;
• 2. expressive language = using sounds, words, and movements to transmit a message;
• 3. receptive language= ability to understand and respond to received messages.

This program is exercised with the help of a specialist which in this case would be a logopedian, but also from the parents who are seen as central figures to the child's changing development. The program's activities have the purpose to focus on the child's communicative abilities. We must know that the program follows the "natural" order of development . So first we use movements, then we use sounds.

What is Logopedy?
Logopedy is a sanitary discipline which deals with communication and language, with the purpose of promoting , preventing or rehabilitating interpersonal communication

Who is the Logopedian?
A Logopedian is the sanitary staff that develops his activity in preventing, assessing and rehabilitating treatment in the pathologies of:

• 1. Voice
• 2. Verbal language
• 3. Written language
• 4. Non-verbal language

A logopedian's goal is bettering a person's health, so that he may use every possible mean of communicating based on his physiological abilities. The goal of the logopedian is to overcome these difficulties, to regain their communicating abilities and use alternative communication and a person's social involvement.

Logopedy in Down Syndrome

Communication is a very important aspect in a DS child's educative program. It is very common for a child with DS to have difficulties in learning language and communicating clearly and properly. These are some of the possible reasons why:

• 1. Muscular Hypotonia of phonic organs, which makes breathing and linguo-bucco-facial articulation hard
• 2. Problems with control and use of nasal cavity and respiratory control
• 3. Problems with sight and hearing
• 4. Low or complex sense perception
• 5. Psyco-motor delay
• 6. Difficulty in chewing and swallowing food

Problems which may affect a child's ability of speech and understanding are:

• a. Articulation - ability to move and control lips, tongue, palate so that proper and clear sound may come out.
• b. Eloquence - the practice or art of using language with fluency and aptness.
• c. Sequence - Ability to pronounce the sounds in the right order ( ephelant instead of elephant)
• d. Resonance - tone and quality of sounds produced by the child.

Fields where there is great need for intervention:

• 1. One of the primary characteristics of children with DS is Hypotonia.
  Hypotonia involves a low muscular tonus which causes difficulties in movement and articulation (example: children with DS have difficulties maintaining their heads straight during latency stage and their tongue stays out of their mouths because the muscles are relaxed). This situation may be presented in different ways. There may be children with good potential of leg usage, but with difficulties in hand movement or children who have hypotonia in all muscles but are good in verbal communication.
  Physical therapy, speech therapy and sports promote muscle growth and strengthening . To achieve this early intervention is needed with physiotherapy, logopedia, psychomotor therapy and development/occupational therapy. On the same time, we must avoid concentrating completely on stimulating the child by maintaining a balance over these interventions.
• 2. Another difficult task for people with DS is communication and language usage.
  - Here are some valid points to support your children in language development To start as early as possible with logopedic therapy, exercises and massages that help the muscles which are used when we speak (tongue, cheek muscles, upper and lower jaw, mouth mucous, lip movement and face mimic) Breastfeeding and spoon feeding help a lot in putting the muscles used to speak into work.
  - To speak frequently to the child during everyday activities by describing them. To work with images and written words. These elements help grow his desire to express, develop his capacity and increase vocabulary.
  - Consult with an Ortophonist/Logopedian and decide on a supporting logopedic therapy. Use a parallel system for nonverbal communication, ( hands, gestures or pictograms) but always use verbal communication as well. This helps the child to be understood by others and avoid frustration. We must be careful, to always prioritize verbal communication in comparison with non verbal communication.
  - Beginning of cognitive-behavior therapy and other forms of therapy conducted by a specialist.
  - Maximal efficacy is achieved when this intervention happens in a child's everyday environment such as family, pre-school or school environment.
  - All these practices should be integrated in everyday activities by becoming spontaneous play.

In general the logopedian intervenes and acts by increasing the level of word selective attention, to know and differentiate sounds and meanings of communication, works with phrase formation and their meaning, as well as with writing and reading. Of course every case is unique, has its own characteristics and it is not meant to have all of these problems. Therefore the logopedic therapy program is not general but rather specific to every child.
Logopedians faces all these problems by creating a specific and individual therapy for each child.

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Children with DS need continuous stimulation since an early age. Adding to what the parents, teachers and therapists will offer to the child in order to keep him active, interested in objects, people and surrounding environment, children with DS will be helped greatly by the early intervention programs to achieve a considerable progress in their development. The early intervention program refers to finding helping programs about dealing with children with DS in scholar age or approximately 6 years old. Early intervention program affects positively in their physical, cognitive, social and language development. This is the evidence shown by pedagogical research.

Of great importance in the achievements of children with DS are intervention programs at a very young age. These programs applied by therapists should be presented spontaneously and it is proven that every exercise is much more efficient if it is integrated as part of a daily program and activities.

We often hear about game therapy and all its benefits. A lot of abilities are improved and modified during this therapy. Because of it, the child grows, develops and learns new ways to express. The game also serves as a detector for the problems the child might have. Introducing the child to the game begins at an early stage, as soon as newborn baby has tendencies to react in all forms and ways to the play. If you start playing with a child, that is an open invitation to make contact, to get closer and share bits of information which can only be provided by such activity. Game therapy includes motor skills such as moving an object, speed, agility, accuracy and hand-eye coordination.

• 1. Solution to the problem - memory and attention.
• 2. Exploration, spatial relations, recognizing colours and forms.
• 3. Visual perception - constant ability of recognition of figures and images even though they might change.
• 4. Hearing perception- ability to recognize and select sounds and interpret them.
• 5. Perception of body and its parts.

Before we can talk about therapy, the needs of the child with DS must be evaluated, so that the program of early intervention may adapt to these needs. The evaluation of needs must be continuous and periodical. Based on the needs and requirements , an Individual Educational Program is planned, based on which, the team made of professionals works with the specific child.

There is no factual evidence that children with DS are different, they are the same as any other child. Every kid is unique and develops at a different pace. This is particular of kids with DS, because their development pace is even more changeable.
Aspects of development in children with DS which require early intervention in order to increase their potential:

• 1. Motor skills: include fine and gross motor skills. A physiotherapist works with gross motor skills while a development therapist works with fine motor skills in 101 ways that include a wide range of exercises and difficulties.
• 2. Cognitive development that includes deficiency in memory, attention, thinking, reasoning and communication. Each one requires different intervention techniques and repetition.
• 3. Social-emotional development : attaching, interpersonal skills, playing and free time help maintain a child with DS's social development normal.
• 4. Personal autonomy: the child with DS must learn to feed, bathe and take care of himself. Once the child has successfully completed these tasks a big part of the fight has been won.
A good development therapy program and rigorous implementation will bring improvements in the child's behaviour and interactions in the future. Like all therapies , development therapy is successful if it brings change and improvement of the child's capacity. However, we must not give up when faced with the results, even though they might not meet our high expectations.

At an older age, in most practices, occupational therapy is also present. All interventions and theoretical orientations have the goal of achieving personal autonomy of child with DS.